Surgical access system and methods

ABSTRACT

A method for retracting tissue in a surgical procedure includes inserting a first blade of a retractor system into an incision in a body of a patient. The retractor system includes a first articulating arm and a second articulating arm. The first articulating arm is coupled to a retractor assembly blade. The retractor assembly blade has a handle portion and the first blade. The second articulating arm is coupled to a bracket securing a second blade. The method includes retracting tissue using the first blade, inserting the second blade into the incision in the body of the patient and retracting tissue using the second blade.

CROSS-REFERENCE TO RELATED APPLICATIONS

This Patent Application is a continuation application of U.S. patentapplication Ser. No. 14/285,177, filed May 22, 2014, which is acontinuation-in-part application of U.S. patent application Ser. No.13/937,960, filed Jul. 9, 2013, which is incorporated herein byreference in its entirety.

TECHNICAL FIELD

This description relates to surgical access systems and methods. Morespecifically, the description relates to a surgical access system andmethod to access the spine of a patient.

BACKGROUND

Retractor systems may be used in a variety of different surgicalprocedures to provide an opening through which the doctor may access thesurgical site. In spinal surgeries, for example, a retractor system maybe used to provide the surgeon with access to the patient's spine. Theopening created by the retractor system may, for example, enable thedoctor to insert surgical instruments into the body or enablevisualization of the surgical site using x-ray.

Traditional spine procedures may involve bluntly dissecting throughtissue and muscles to treat the appropriate levels of the spine. Thus,there is a need that allows for a more refined and controlled approachto spine procedures.

SUMMARY

According to one general aspect, a method for retracting tissue in asurgical procedure includes inserting a first blade of a retractorsystem into an incision in a body of a patient. The retractor systemincludes a first articulating arm and a second articulating arm. Thefirst articulating arm is coupled to a retractor assembly blade. Theretractor assembly blade has a handle portion and the first blade. Thesecond articulating arm is coupled to a bracket securing a second blade.The method includes retracting tissue using the first blade, insertingthe second blade into the incision in the body of the patient andretracting tissue using the second blade.

Implementations may include one or more of the following features. Forexample, the method of may further include independently positioning thefirst blade and the second blade using the first articulating arm andthe second articulating arm, respectively. Retracting tissue using thefirst blade may include retracting the peritoneum anteriorly out of asurgical corridor. Retracting tissue using the second blade may includeretracting a posterior wall of the surgical corridor.

The retractor assembly blade may include a hinge mechanism connectingthe handle portion and the first blade and the method may includepositioning the first blade at an angle relative to the handle portionusing the hinge mechanism.

The method may further include prior to inserting the first blade of theretractor system into the incision, inserting a flexible retractor intothe incision to provide a surgical corridor to a surgical sit

The method may further include inserting a second retractor system intothe incision. The second retractor system may include a frame having aplurality of blades and a plurality of movable arms with each of theblades coupled to the frame through one of the movable arms. The methodmay include angulating each of the blades of the second retractorsystem. The method may further include retracting each of the blades ofthe second retractor system. Inserting the second retractor system mayinclude inserting the second retractor system into the incision in aclosed position. The plurality of blades may include a single posteriorblade and two cephalad-caudal blades. The method may further includeinserting at least one light cable through at least one of the blades toilluminate a surgical site.

In another general aspect, a medical device includes a first mountingbracket, a first articulating arm coupled to the first mounting bracket,a second articulating arm coupled to the first mounting bracket, and aretractor assembly blade coupled to the first articulating arm. Theretractor assembly blade has a handle portion and a first blade. Asecond mounting bracket is coupled to the second articulating arm. Thesecond mounting bracket secures a second blade.

Implementations may include one or more of the following features. Forexample, the first blade and the second blade may be independentlypositioned using the first articulating arm and the second articulatingarm, respectively. The retractor assembly blade may include a hingemechanism connecting the handle portion and the first blade. The hingemechanism enables the first blade to move and lock in multiple differentpositions relative to the handle portion. The handle portion of theretractor assembly blade may include an elongate member with a firstmounting location on one side of the elongate member and a secondmounting location on an opposite side of the elongate member, witheither of the first mounting location or the second mounting locationused to couple to the first articulating arm. The second mountingbracket may include a first mounting location on one side of the secondmounting bracket and a second mounting location on an opposite side ofthe second mounting bracket, with either of the first mounting locationor the second mounting location used to coupled to the secondarticulating arm.

In other example embodiments, the second mounting bracket may include afirst mounting location on one side of the second mounting bracket and asecond mounting location on an opposite side of the second mountingbracket to enable the second mounting bracket to couple to twoarticulating arms.

In another general aspect, a method for retracting tissue in a surgicalprocedure includes inserting a flexible retractor into an incision in abody of a patient to provide a surgical corridor to a surgical site andinserting a first blade of a retractor system into the incision in thebody of the patient through the flexible retractor. The retractor systemincludes a first articulating arm and a second articulating arm. Thefirst articulating arm is coupled to a retractor assembly blade. Theretractor assembly blade has a handle portion and the first blade. Thesecond articulating arm is coupled to a bracket securing a second blade.The method includes retracting tissue using the first blade, insertingthe second blade into the incision in the body of the patient, andretracting tissue using the second blade. Sequential dilation isperformed using a plurality of dilators. The method includes inserting asecond retractor system into the incision over a largest of thedilators. The second retractor system includes a frame having aplurality of blades and a plurality of movable arms with each of theblades coupled to the frame through one of the movable arms. The methodincludes angulating each of the blades of the second retractor systemand retracting each of the blades of the second retractor system.

Implementations may include one or more of the following features. Forexample, the method may further include independently positioning thefirst blade and the second blade using the first articulating arm andthe second articulating arm, respectively.

The details of one or more implementations are set forth in theaccompanying drawings and the description below. Other features will beapparent from the description and drawings, and from the claims.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a perspective view of a medical device according to anembodiment of the invention.

FIG. 2 is a perspective view of a retractor assembly blade of themedical device of FIG. 1 according to an embodiment of the invention.

FIG. 3 is a perspective view of a retractor assembly blade of themedical device of FIG. 1 according to an embodiment of the invention.

FIG. 4 is a partial perspective view of a retractor assembly blade ofthe medical device of FIG. 1 according to an embodiment of theinvention.

FIG. 5 is a perspective view of a retractor assembly blade in a foldedposition of the medical device of FIG. 1 according to an embodiment ofthe invention.

FIG. 6 is a top view of a mounting bracket of the medical device of FIG.1 according to an embodiment of the invention.

FIG. 7 is a perspective view of a mounting bracket of the medical deviceof FIG. 1 according to an embodiment of the invention.

FIG. 8 is a perspective view of a mounting bracket of the medical deviceof FIG. 1 according to an embodiment of the invention.

FIG. 9 is a perspective view of a k-wire stop according to an embodimentof the invention.

FIG. 10 is a cross-section view of the k-wire stop of FIG. 9 accordingto an embodiment of the invention.

FIG. 11 is a perspective view of a k-wire stop according to anembodiment of the invention.

FIGS. 12-38 illustrate steps of a surgical technique and the medicaldevices used in the surgical technique according to an embodiment of theinvention.

DETAILED DESCRIPTION

Detailed implementations of the present invention are disclosed herein;however, it is to be understood that the disclosed implementations aremerely examples of the invention, which may be embodied in variousforms. Therefore, specific structural and functional details disclosedherein are not to be interpreted as limiting, but merely as a basis forthe claims and as a representative basis for teaching one skilled in theart to variously employ the present invention in virtually anyappropriately detailed structure. Further, the terms and phrases usedherein are not intended to be limiting, but rather to provide anunderstandable description of the invention.

The terms “a” or “an,” as used herein, are defined as one or more thanone. The term “another,” as used herein, is defined as at least a secondor more. The terms “including” and/or “having”, as used herein, aredefined as comprising (i.e., open transition).

The devices and methods (or techniques) described herein are generallydirected to medical devices that can be used to provide directvisualization and access to a surgical site within a body of a patient.More specifically, the system and techniques described provides surgicalinstrumentation and method of use which allows for direct visualizationof the muscle layers and corresponding nerves to avoid complicationsduring and after a spinal fusion procedure, such as a lateral lumbarfusion surgery.

The term patient may be used hereafter for a person who benefits fromthe medical device or the methods disclosed in the present invention.For example, the patient may be a person whose body receives the medicaldevice disclosed by the present invention in a surgical treatment. Forexample, in some embodiments, the patient may be a human female, humanmale, or any other mammal.

FIG. 1 is a perspective view of a medical device 10 according to anembodiment of the invention. The medical device 10 may be one of thecomponents of the surgical system to allow for direct visualization andaccess during spinal surgery. In one example embodiment, medical device10 is a peritoneal retractor that may be used to retract tissue in asurgical procedure, as further described below with the use of thedevice and its use in a particular surgical technique. In other exampleembodiments, the medical device 10 may be used in other types ofsurgeries and surgical procedures.

The medical device 10 includes a retractor assembly blade 12, arms 14Aand 14B, arm mounting bracket 16 (also referred to as mounting bracket16) and blade mounting bracket 18 (also referred to as mounting bracket18). The medical device 10 may be secured to a surgical table or otherdevice using a mount 20. For example, the mount 20 may be a table mountthat secures the medical device 10 to a bedrail or other rail orcomponent on a surgical table.

The medical device 10 allows for multiple independent blades to beinserted into a patient and to provide direct access and visualizationto the muscles and tissues near the spine. For example, the medicaldevice 10 may include one blade as part of the retractor assembly blade12 and a another blade that is connected to the blade mounting bracket18. Both blades may be inserted into the surgical site to access andretract tissue.

The retractor assembly blade 12 may be secured and connected to the arm14A. The retractor assembly blade 12 includes a handle portion 22 (orhandle 22) and a blade portion 24. Examples of the retractor assemblyblade 12 are illustrated in FIGS. 2-5 and described with respect tothose figures in more detail below. The handle portion 22 may provide agrip area to allow a surgeon to hold and retract tissue by gripping thehandle portion 22. The handle portion 22 includes a distal end 26 and aproximal end 28. The handle portion 22 at the proximal end 28 includesone or more connection points 30A and 30B for connecting to the arm 14A.The connection points 30A and 30B also may be referred to as mountinglocations or arm mounting locations. The connection points 30A and 30Bmay be on either side of the handle portion 22. In this manner, thehandle portion 22 may connect to the arm 14A on either side of thehandle 22. In other example embodiments, the handle portion 22 mayconnect to two arms with one arm connected to connection point 30A andthe other arm connected to connection point 30B.

The distal end 26 may include a curved portion 32. The curved portion 32may allow a surgeon to grab or hold the curved portion and pull theretractor assembly blade 12 in a desired direction and/or orientation.The curved portion 32 may allow a doctor to position the retractorassembly blade 12 in a desired manner.

The blade portion 24 is connected to the handle portion 22 near theproximal end 28 of the handle portion 22. The blade 24 may be aremovable component of the retractor assembly blade 12. Different typesof blades may be used with the same handle portion 22. The blade 24 thatmay connect to the handle portion 22 may have varying lengths and/orwidths, as illustrated in more detail in FIGS. 2-5.

The blade portion 24 may include a cannulation through at least aportion of its length from the proximal end to the distal end to allowfor a self-retained light source. The self-retained light source (notshown) may be inserted through the blade cannulation and used toilluminate a surgical corridor and/or surgical site. The handle portion22 may include one or more tabs 34 to hold a cable or other wire for thelight source and to keep the cable out of the operative field.

The arms 14A and 14B allow maneuverability of the retractor assemblyblade 12 and the mounting bracket blade 18 in the operative field inmultiple directions and/or planes. While the description of one arm 14Amay be described, it is understood that the description applies equallyto the arm 14B. The arms 14A and 14B may be referred to asmini-articulating arms. Each arm 14A and 14B may be positionedindependent of each other thus providing independent positioning andmaneuverability of respective blades or blade assemblies attached to thearticulating arms 14A and 14B.

Each arm 14A and 14B may include one or more smaller component arms36A-36D. The smaller component arms 36A-36D each have a proximal end 38and a distal end 40. The proximal end 38 on each of the arms 36A-36D mayconnect to or may provide a connection point to another arm. Forexample, the proximal end 38 on arm 36A provides a connection point tothe proximal end 38 on arm component 36B. The smaller component arms36A-36D may be joined to the other component arms in a number of waysincluding a rotationally captured fit, a pin and hole connection, atelescoping connection, a translation connection or similar connection.In this example embodiment, the proximal end of each smaller componentarm includes a hole through which a pin 42 may be inserted to connectone arm to another arm. The pin 42 may be tightened and un-tightened tosecure the arms in relation to one another.

Each of the arms 36A-36D may include a knob portion 44A-44D (or knob44A-44D). In one example embodiment, the knob portions 44A-44D may belocated between the proximal end and the distal end. The knob portions44A-44D may be used to lock the arms in a desired position, The knobsmay rotate from one position to at least one other position to lock andunlock the movement of the arms. For example, when the knob portion44A-44D is in a first position the arm may be in a locked position. Whenthe arm is locked in place, it may be prevented from furtherarticulation and movement. When the knob is in a second position, thearm may be unlocked and capable of articulating into a desired position.

The distal end 40 of each of the arms 36A-36D includes a lockingmechanism 46A-46D. The locking mechanisms 46A-46D provide a connectionpoint to another component of the medical device 10. For example, thelocking mechanism 46A-46D may connect and lock to a bracket, such asmounting bracket 16 or mounting bracket 16. In the illustrated example,component arm 36A includes a locking mechanism 46A that locks andconnects to the retractor assembly blade 12. The component arm 36Bincludes a locking mechanism 46B that connects and locks to the mountingbracket 16. Similarly, component arm 36D includes a locking mechanism46D that also connects to the mounting bracket 16. The component arms36C includes a locking mechanism 46C that connects to the mountingbracket 18.

The locking mechanisms 46A-46D may include different types of lockingfeatures that provide a positive locking feature to connect the arms 14Aand 14B to the brackets. Examples of locking mechanisms include, but arenot limited to, tongue and groove, bolts and slot, screw and threadedhole, and interference fit. In the illustrated embodiment, a screw andthreaded hole feature is used to connect the arms 14A and 14B to thebrackets and/or retractor assembly blade.

While the illustrated embodiment shows to smaller component arms joinedto make single articulating arms, it is possible that combinations ofmore than two smaller component arms may be used to form a singlearticulating arm. For example, component arm 36A and 36B formarticulating arm 14A. In the same manner, component arm 36C and 36D formthe articulating arm 14B.

In the illustrated embodiment, mounting bracket 16 includes threeconnection points (or mounting locations). In other example embodiments,the mounting bracket 16 may include more or less connection points. Inthis example, the bracket 16 may be referred to as a “Y-type” connectorthat includes a single attachment point on one side and multipleattachment points on the other side. The mounting bracket 16 may includean elongate member 48. In the illustrated embodiment, there are twoconnection points on one side of the elongate member 48 and oneconnection point on the other side of the elongate member 48. Arm 14Aconnects to the one connection point using the locking mechanism 46B tomake a secure attachment to the bracket 16. Arm 14B makes a connectionto the other connection point using the locking mechanism 46D to make asecure attachment to the bracket 16. The other connection point connectsto the table arm 20 and provides a secure attachment to the table arm20.

The mounting bracket 18 includes a slot 50 to accept a blade 52. Theslot 50 may receive the blade 52 and lock the blade 52 into the slot 50using the locking mechanism 54. In the illustrated embodiment, thelocking mechanism 54 may also be referred to as a blade locking nut. Thelocking mechanism 50 may be rotated to a first position to allow theinsertion and removal of the blade 52 into the mounting bracket 18. Thelocking mechanism 54 may be rotated or moved into a second position tolock the blade 52 into the bracket 18. When the locking mechanism 54 isin the second position, the blade 52 is prevented from being removedfrom the bracket 18.

The mounting bracket 18 includes multiple attachment points 56A and 56B.The attachment points may be on either side of the bracket 18. In thismanner, the arm 14B may be connected to either side of the mountingbracket 18. In the illustrated embodiment, the attachment points 56A and56B each include a slot (57A for connection point 56A) to receive thelocking mechanism, such as locking mechanism 46C.

In use, the medical device 10 may be used to help retract the peritoneumout of the surgical corridor. The medical device 10 may be a peritonealretractor that is inserted into an incision and used to retract theperitoneum out of the surgical corridor. The use of the medical device10 is illustrated and described in more detail below with respect to thedescribed surgical technique of FIGS. 12-38.

FIGS. 2-5 illustrate a portion of the medical device 10. In theillustrated example of FIG. 2, the portion of the medical device 10illustrated includes the retractor assembly blade 12 connected to one ofthe articulating arms 14A. FIG. 3 illustrates the retractor assemblyblade 12 in an open position, where the handle portion 22 and the bladeportion 24 are open at an angle with respect to one another. The handleportion 22 and the blade portion 24 may rotate about a hinge mechanism58. The hinge mechanism 58 may allow the handle portion 22 and the bladeportion 24 to rotate about a point with respect to each other from afolded (or closed) position, as illustrated in FIG. 5, to an openposition, as illustrated in FIGS. 2-4. The hinge mechanism 58 may be apush button type mechanism that when pushed allows the handle portion 22and the blade portion 24 to be positioned through varying angles withrespect to each other and when released may lock the portions into adesired position. For example, the handle portion 22 and the bladeportion 24 may be rotated in multiple positions through 180°. Theretractor assembly blade 12 may be locked into any one of the multiplepositions along the movement of travel about the hinge mechanism 58. Inother example embodiments, other types of hinge mechanisms may be usedto enable the portions to rotate about each other and to lock into adesired position.

The blade portion 24 may be independent of the handle portion 22. Inthis manner, differing blade portions may be used with the same handleportion 22. The handle portion 22 may include a tongue 59 and the bladeportion may include a slot 60 into which the blade and handle portionare slid in a tongue and groove fashion, which works to secure the bladeportion into handle portion. The blade portion 24 may include a straightelongate member 62 and a curved portion 63 at a distal end of theelongate member 62 and the curved portion 63 may be of varying lengthsand/or widths. The distal end 66 of the blade portion 24 may be bluntedto prevent tissue damage. The curved portion 63 may be used to aid inthe engagement of tissue material during a surgical procedure.

In the illustrated embodiment, the blade portion 24 may be concave on aninner surface and convex along an outer surface. The curved portion 63may be spoon-shaped to allow for engagement of tissue at a surgicalsite. The elongate member 62 may be substantially linear. In otherexample embodiments, the elongate member 62 may include a slightcurvature and be non-linear.

FIGS. 3 and 4 illustrate the retractor assembly blade 12 in full (FIG.3) and in part (FIG. 4) without being attached to the rest of themedical device 10. In these illustrated embodiments of FIGS. 3 and 4,the blade portion 24 may have a varying width at the distal end 66. Forexample, in FIG. 3 the curved portion 63 has a first width 64. In FIG.4, the distal end 66 at the curved portion 63 has a second width 65 thatis different from the width 64 is illustrated in FIG. 3. In otherexample embodiments, different blades may have different lengths aswell.

FIG. 5 illustrates the retractor assembly blade 12 in a folded (orclosed) position. As discussed above, the handle portion 22 and theblade portion 24 may rotate about a hinge mechanism 58. In this example,the blade portion 24 has been rotated and disposed beneath the handleportion 22. The folded position also may be referred to as a closedposition. The hinge mechanism 58 may include a push button to allow theunlocking of the portions with respect to each other and allow them torotate from the folded or closed position to a different positionthrough multiple different positions and angles with respect to eachother.

FIG. 6 illustrates the mounting bracket 18. The mounting bracket 18, asdescribed above, may be used to connect to one of the arms of themedical device 10 and to mount a blade 52 into the bracket 18. In thisillustrated example, the mounting bracket 18 includes multipleconnection points 56A and 56B (not shown in FIG. 6) to enable thebracket 18 to connect to one of the arms of the medical device 10. Thebracket 18 is locked to the arm using the locking mechanism 46C on thearm.

In other example embodiments, the bracket 18 may be locked to the armusing the other connection 56A. In other example embodiments, twoarticulating arms may be connected to the bracket 18.

As discussed above with respect to FIG. 1, the locking mechanism 54 maybe rotated between positions to allow the insertion and removal of theblade 52 into the bracket 18. In this example, FIG. 6 illustrates a topview of the bracket 18 and the blade 52. The blade 52 may include acannulation 68. The cannulation 68 may be used to insert a light sourcethrough the blade to provide illumination at the distal end of theblade. The illumination provided by the light through the cannulation 68helps to illuminate the surgical site.

The bracket 18 includes a hook 70 and a hook 71 to engage the blade 52and hold the blade into the slot 50. In other example embodiments, othertypes of mechanisms may be used to hold the blade 52 into the slot 50.

In one example embodiment, multiple arms may be used to connect to thesame bracket 18. For example, one arm may be connected to one side ofthe bracket and another arm may be connected to the other side of thebracket. Each of the arms may be locked into position to secure thebracket onto the arm.

FIG. 7 illustrates the mounting bracket 18 as a separate component. Asdiscussed above, the mounting bracket 18 includes multiple connectionpoints 56A and 56B. In this manner, multiple arms may be connected toeither side of the bracket 18.

FIG. 8 illustrates the mounting bracket 16. The mounting bracket 16 maybe used as an adapter to attach the arms 14A and 14B to a larger tablearm. In the illustrated example, the mounting bracket 16 includes threemounting locations to interface with the different arm connections. Themounting locations 49A-49C provide the connection points to the arms14A, 14B and 20.

As discussed above, the mounting bracket 16 includes an elongate member48. The elongate member 48 includes the connection points 49A-49C. Whilethe illustrated example shows three connection points, other numbers ofconnection points may be included along the elongate member 48.

FIGS. 9-11 illustrate K-wire stop 76. FIG. 9 illustrates the K-wire stop76, FIG. 10 illustrates a cross-section of the K-wire stop 76 and FIG.11 illustrates the K-wire stop 76 resting on a dilator 77. The K-wirestop 76 includes a nut 78 and a body 79. The K-wire stop 76 grips aK-wire 80 and holds it in a desired location while inserted into aninitial dilator 77. With the K-wire 80 inserted into the assembly,rotating the nut 78 will clamp the body 79 onto the K-wire. The use ofthe K-wire stop 76 is described in more detail below with respect toFIGS. 12-38 as used in the surgical technique as described below.

FIGS. 12-38 describe an example surgical technique using one or more ofthe components from medical device 10 in cooperation with one or moreother components in the context of the surgical technique. In oneexemplary embodiment, the technique includes accessing a desiredsurgical site, which may be, for example, a spinal disc in a lateralapproach under direct visualization. The following exemplary techniquedescribes a set of steps in a particular order; however, it should beunderstood that changing the order the steps or not completing all thesteps is contemplated.

FIGS. 12 and 13 illustrate a first step of the surgical technique. Thefirst step includes patient preparation and patient positioning. Thepatient 1200 is placed on a flexible surgical table 1210. The patientmay be placed on the flexible surgical table 1210 in a true 90° rightlateral decubitus position so that the iliac crest is just over adesired portion of a surgical table 1210 that the patient 1200 is placedupon. As illustrated in FIG. 13, the surgical table 1210 may be capableof bending or breaking in one or more places, such as location 1220. Thedesired position may be to place the patient 1200 over such a break 1220as shown in FIG. 13. In an example embodiment, the table 1200 should beflexed to open the interval between the 12^(th) rib and the iliac crestand provide direct access to the disk space.

As shown in FIG. 12 the patient may be secured to the table 1200 at thefollowing locations (1) just beneath the iliac crest 1230; (2) over thethoracic region, just under the shoulder 1240; (3) from the back of thetable, over the ankle 1250; and (4) past the knee to the front of thetable 1250.

As part of the surgical technique of step one, fluoroscopy may be usedto confirm accurate placement and positioning of the patient to allowthe appropriate access to the desired surgical site. FIG. 14 illustratestwo images 1410 and 1420. These example images illustrate a lateralimage 1410 and an AP image 1420. The surgical table should be adjustedso that the C-arm provides true AP images when at 0° and true lateralimages at 90°.

Also as part of step one of the surgical technique, FIG. 15 illustratesthe use of an incision locator 1510 to identify the incision location onthe patient. For example, the operative area is carefully cleaned andthe incision locator 1510 may be used under fluoroscopy to identify themiddle of the disk space to be fused. An access incision mark 1520 maybe traced on the patient's skin to indicate the position and insertionsite for the medical components to be used during the surgicaltechnique. For example, the access incision mark 1520 may be used toindicate the position and insertion site for the medical device 10, aswell as other components to be used during the procedure.

FIGS. 16 and 17 illustrate a next step in the surgical technique. In theexemplary technique, the next step includes making an incision in thepatient about the desired surgical destination. For example, the nextstep may include making an incision 1610 above the spinal disc that isto be addressed. In one example embodiment, the incision 1610 may besized such that allows for eventual direct visualization of the surgicalsite. The incision size may vary based on the amount of eventualvisualization desired. One exemplary incision size may be 2 inches. Forexample, the incision 1610 may be a small, oblique 2 inch incision abovethe targeted disk space. In other example embodiments, multipleincisions may be used if there are going to be multiple desired surgicaldestinations.

Once the incision 1610 is made, in an example technique, dissectionthrough the skin fascia and adipose tissue may be accomplished usingbipolar forceps 1710, as illustrated in FIG. 17. The initially dissectedtissue may be held in place via the use of a retractor, such asWietlaner Retractor 1720.

FIG. 18 illustrates a next step in the surgical technique. The next stepmay include splitting the muscle in the patient above the desiredsurgical destination. For example, in a lateral technique that willaddress a spinal disc, the external oblique muscles, internal obliquemuscles and transverse abdominal muscles are split in line with thefibers of each level. In an example technique, it is contemplated thatduring this step to be cognizant of cutaneous nerves while movingbetween the muscle layers. One or more surgical instruments may be usedduring this step of the technique. For example, a combination of theLong Metzenbaum Scissors, forceps, bipolar forceps, and 8 inch suctionmay be used.

FIG. 19 illustrates a next step in the example surgical technique. Thenext step may include inserting a retractor into the incision 1610. Forexample, once the external oblique muscles, internal oblique muscles,and transverse abdominus muscles have been split, a flexible woundretractor 1910 may be inserted. The flexible wound retractor 1910 may beself-retaining and may provide a consistent surgical corridor to accessthe surgical site. For instance, the flexible wound retractor 1910 mayprovide a consistent surgical corridor to access the psoas.

The first part of the step is illustrated in image 1920. The image 1920illustrates inserting the retractor 1910 by first squeezing a blue ringto collapse while inserting into the incision 1610. The blue ring shouldrest on top of the psoas muscle. The ring may be gently pulled to ensureproper fit in the incision 1610, with the white ring positioned on topof the skin. The next portion of the step is illustrated in the image1930. In the image of 1930, the hands are positioned at 11 and 1o'clock. The next portion of the step is illustrated in the image 1940.In this image, the white ring is rolled down outwards first with theleft hand and followed by the right hand. This process is repeated 2 to3 times until desired exposure is achieved.

FIGS. 20-23 illustrate the next step in the surgical technique. In thisstep illustrated by FIGS. 20-23, the medical device 10 described abovewith respect to FIGS. 1-8 is inserted into the incision. As discussedabove, medical device 10 may be referred to as a peritoneal retractorthat is inserted into the incision to help retract the peritoneum out ofthe surgical corridor. The use of the medical device 10 may begin byfirst attaching the table clamp over the drape and onto the bed railattachment. Then, the articulating arm assembly may be inserted into theclamp and secured.

FIG. 20 illustrates attaching the mounting bracket 16 to the table arm20. FIG. 21 illustrates attaching the arms 14A and 14B to the mountingbracket 16. Next, FIG. 22 illustrates the attachment of the retractorassembly blade 12 to the arm 14A and inserting the retractor assemblyblade 12 through the flexible wound retractor 1910. Prior to insertioninto the flexible wound retractor, an appropriate sized blade may beselected for attachment to the retractor assembly blade 12. Theretractor assembly blade 12 is inserted through the flexible woundretractor 1910 to secure the peritoneum anteriorly. The retractorassembly blade 12 may be individually positioned as needed by unlockingthe arm 14A such that it may move into any desired position and or planeand then locking the arm into the desired position. As discussed above,the arm 14A and its attached retractor assembly blade 12 may beindividually positioned as needed separate from the arm 14B and any ofblade attached to that arm.

FIG. 23 illustrates that a blade may be attached to the arm 14B throughthe mounting bracket 18. For example, a MARS 3V posterior blade fromGlobus Medical Inc. may be attached to retract the posterior wall of thesurgical corridor. In the illustrated example, the blade mountingbracket 18 is secured to the arm 14B. The desired posterior blade 52 canthen be attached to the bracket 18 using a hook and latch driver andlocked into position using the locking mechanism 54.

As described above with respect to the medical device 10, the blade 24in the retractor assembly blade 12 may be positioned relative to thehandle portion 22 of the retractor assembly blade using the hinge pin58. The blade 24 and the blade 52 may be independently moved and/oradjusted as needed by loosening the respective arms 14A and 14B,repositioning the arms 14A and 14B to a desired position and re-lockingthe arms in the desired position.

In some embodiments, the blades 24 and 52 can be attached to the arms14A and 14B, which are attached to a table mount. In some embodiments,the arms can part of a Globus Medical's MARS™3B 4^(th) arm attachment.Advantageously, by attaching the arms 14A and 14B to a table mount, theblades 24 and 52 can be held hands-free, thereby reducing exhaustion inthe surgeon and freeing the surgeon's hands to do other things.

FIGS. 24 and 25 described the next step in the example surgicaltechnique. The next step may be performed through the medical device 10.In this step, access is provided to the transpsoas. First, thegenitofemoral nerve may be located and swept to the posterior aspect ofthe surgical corridor. The psoas fascia may be opened using acombination of endoscopic kitners and Metzenbaum scissors. Releasing thefascia releases tension on the muscle and the genitofemoral nerve,allowing a safer passage for sequential dilation.

FIG. 26 illustrates a next step in the surgical technique. In the nextstep, sequential dilation may be performed. As part of the sequentialdilation, the K-wire stop described above with respect to FIGS. 9-11 maybe used. The K wire stop, which is optional, may be deployedconcurrently with an initial dilator. The initial dilator may be placedwith the K-wire extending through a lumen of the initial dilator and theK-wire stop may be used to limit how far the K-wire will extend from thelumen at the distal end of the dilator. The K-wire may be sized so thatit will be abut the proximal end of the initial dilator preventing theK-wire from extending further through the lumen of the initial dilator.Once the K-wire and initial dilator reach the desired location, the stopcan be loosened and removed allowing the K-wire to be pushed into thetissue to be addressed to serve as a locational guidepost. Then,sequential dilation may take place and the retractor described in thenext figures may be placed over the largest dilator. For example, afirst cannula may be used to locate the appropriate part of the disc forK-wire insertion and may be verified with fluoroscopy, as needed. Thedisc may feel like a small bump on the lateral aspect of the spine. Thelumbar plexus branches should be posterior to the first cannula and notdocked within a branch of the plexus. The K-wire may be inserted throughthe first cannula and into the disc and sequential dilation may be usedusing multiple cannulas such as second and third cannulas.

FIGS. 27-38 described the next step in the example surgical technique.In this example step, a retractor may be used and inserted to access thesurgical site and provide assistance in direct visualization of thesurgical site. In one example embodiment, a MARS 3V retractor fromGlobus Medical, Inc. may be used. The retractor, such as the onedescribed in U.S. Pat. No. 8,353,826 (the '826 patent) may be used toretract the tissue. The '826 patent is hereby incorporated by referencein its entirety.

FIG. 27 illustrates the retractor 2700. The appropriate blades may beselected and inserted into each of the three blade mounts of the bladeframe 2702. For example, a posterior blade 2710 may be inserted into theposterior blade mount 2712. For the other blades, a cephalad-caudal (CC)blade 2720 may be inserted into the other blade mounts.

FIG. 28 illustrates ensuring that the blades are properly seated intothe retractor 2700. For example, the blades should be properly seatedinto the retractor 2700 at each of the three positions. The blades maybe secured using a hook and latch driver 2810. The driver 2810 may bepositioned on the latch and rotated 90° clockwise to lock the blade inplace. The blades can be changed intra-operatively when a differentblade length is required. The blades include angled holes to accept thedriver. The driver may be inserted and tightened down on the whitesleeve to hold the blade securely. This provides a secure connection toremove the blade.

FIG. 29 illustrates the retractor positioning. Ensure that the retractor2700 is in the fully closed position and the blades are securelyattached to the frame. The access incision should allow the blades toretract and angulate. Slide the retractor over the third cannula 2910and apply gentle downward pressure on the frame. Before removing thecannulas, angulate all three blades to one full turn of the silver knobs2912A-2912C. Retract all three blades to two clicks using the gold knobs2914A-2914C. The blade closest to the iliac crest should be retractedfirst. Angulating and retracting the blades in this manner will helpprevent tissue creep as the cannulas are removed.

At this point, the peritoneal retractor, or medical device 10, may bedetached from the articulating arm assembly use a 10 mm socket driver toremove the arm mounting bracket from the arm. Position the arm andattach to the MARS 3V retractor mounts. Once the retractor has beensecurely positioned and the arm tightened, remove the cannulas andverify the position of the retractor before removing the K-wire. APfluoroscopy may be used to verify the correct positioning on the spineand to confirm that the retractor blades are parallel with the discspace.

FIG. 30 illustrates the attachment of the medical device 2700 to thetable arm 3010. The table clamp may be attached over the drape and ontothe bed rail attachment. The articulating arm assembly may be insertedinto the clamp and secured. The opposite end of the assembly arm is thenattached to the retractor 2700. There are two options for attachmentpositions on the retractor as shown in FIG. 30 at 3012A and 3012B.Attaching the arm assembly to 3012 a maintains retract position relativeto the posterior blade position and translates the cephalad and caudalblades interiorly when the retractor is opened. Attaching the armassembly to attachment 3012B maintains the retractor position relativeto the center of the frame and retracts all three blades when theretractor is opened.

FIG. 31 illustrates the table arm attachment. The articulating armassembly may be inserted into the desired attachment positioned andtightened the thumbscrew 3110 using a 10 mm socket driver 3120. The armmay be positioned and locked in place by tightening the handle on thearm assembly. Minimal torque may be required to tighten the thumbscrewwith the driver 3120. Manipulation of the retractor can be achieved withthe frame handle that fits over the arm attachment point.

FIG. 32 illustrates the light cable insertion into the retractor 2700.One or more light cables 3210A and 3210B may be inserted into theblades. The light cables should be inserted through the blade to a depthproviding optimal visibility. The fiber optic cord may attach to thelight source used for headlamps or endoscopes. The adapters accommodatean ACMI, Olympus, Storz, or Wolf light source.

FIGS. 33 and 34 illustrate the cephalad-caudad blade anchoring. Foradditional retractor stability, docking pins such as docking pins 3310may be inserted into the vertebral body through the blades to increaseretractor stability when expanding the blades for greater exposure asshown in FIG. 34. Different size pins may be used and inserted into thedocking pin sleeve 3320. The pin assembly can slide down the T-slot oneither side of the blade. The docking pin tool includes a hex featurethat mates with the head of the pin. The tool may be rotated clockwiseto engage pin threads into the bone. To remove the pins, re-engaged thehex of the tool into the pin head and rotate counterclockwise todisengage from the bone.

FIGS. 35-38 illustrate the blade expansion of the retractor 2700. Eachblade may be independently expanded using the 10 mm socket driver 3510to rotate the respective gold hex nut in the direction indicated by thearrow 3630. Each blade may be angled up to 20° using the driver. Thedriver 3510 may be placed onto the silver hex nut and rotate theinstrument clockwise, allowing the blade to tilt to the desired positionas illustrated in FIG. 35.

As illustrated in FIG. 36, a widening shim 3610 may be used to preventsoft tissue creep between blades. The shim 3610 may be used to slidedown the T-slot on either side of the blades for an additional 22 mm ofblade width. The shim provides additional blade width. In other exampleembodiments, the shim may provide other widths. A tool may be used toinsert the shim down the T-slot on either side of the blades.

FIG. 37 illustrates the use of a lengthening shim 3710. The lengtheningshim 3710 may be used to help prevent soft tissue creep between bladesby increasing the length of the blade to maintain bone contact. Whileangulating the CC blades, lengthening shims can be used. A shim tool maybe used to push the lengthening shim down the right T-slot of theblades.

FIG. 38 illustrates the removal of the widening shim 3610 and thelengthening shim 3710. Both the widening and lengthening shims haveangled holes to accept the hook on the shim tool. The hook may beinserted and pulled upwards to remove the shims.

FIGS. 19A-19D illustrate alternative steps that can be substituted forthe step involving a wound retractor, as shown in FIG. 19. These stepsinvolve the use of one or more rigid retractors (e.g., DeaverRetractors) to a) retract the peritoneum lining and b) expose the psoasmuscle. FIGS. 19A and 19B illustrate the step of retracting theperitoneum using the Deaver Retractors, while FIGS. 19C and 19Dillustrate the step of exposing the psoas muscle using the DeaverRetractors.

In some embodiments, once the external oblique muscles, internal obliquemuscles, and transverse abdominus muscles have been split, rather thaninserting a flexible retractor, one or more rigid retractors can be usedto retract the peritoneum (as shown in FIGS. 19-A and 19-B. In someembodiments, two Deaver Retractors can be inserted superficially to thepsoas. One of the Deaver Retractors can be placed anteriorly, while theother can be placed posteriorly, relative to the disc space. As shown inFIG. 19-A, Deaver Retractor 3810 is an anterior retractor, while DeaverRetractor 3812 is a posterior retractor. The anterior retractor can bepositioned closer to the peritoneum than the posterior retractor. Theanterior retractor can be used to dissect fat off of the peritoneum andretract anteriorly above the psoas. In some embodiments, a wet mini lap3850 can be advantageously used as a buffer between the anteriorretractor and the peritoneum to protect the peritoneum duringretraction. In some embodiments, the wet mini lap can be comprised atleast in part of a spongeous material to assist in preventing damage tothe peritoneum by the anterior retractor.

After retracting the peritoneum, the psoas muscle can be exposed, asshown in FIGS. 19-C and 19-D. In some embodiments, to expose the psoasmuscle, the Deaver Retractors 3810 and 3812 can be pulled back toseparate the retroperitoneal space. As in FIGS. 19-C and 19-D, a wetmini lap 3850 can be used as a buffer between one or more of theretractors 3810, 3812 and the peritoneal to protect the peritonealduring additional retraction. In addition, one or more endoscopicdissector sticks 3840 can be used to also assist in the dissection andsoft separation of the retroperitoneal space. In some embodiments, oneor more of the endoscopic dissector sticks 3840 includes a distal endthat is soft like a q-tip. This separation advantageously provides a“direct look” at the psoas muscle, whereby the psoas muscle is visiblewithout the use of additional navigation tools. In some embodiments,this “direct look” technique can be used in conjunction with navigationtools, such as neuromonitoring tools, to further access the psoas.

After the psoas muscle has been exposed, the Deaver Retractor 3810 onthe anterior side of the disc space can be swapped out and replaced withthe medical device 10 (e.g., peritoneal retractor). For example, aretractor assembly blade 12 (shown in FIG. 1) of the peritonealretractor can be used to replace the anterior Deaver Retractor. As notedabove, the peritoneal retractor is a hands free alternative to theDeaver Retractor that can be attached to an articulating arm assembly.In some embodiments, the peritoneal retractor is accompanied by an MISillumination system to aid in viewing the inner tissues and muscle. Insome embodiments, the illumination system comprises a light sleeve thatis inserted downwardly through a groove in the peritoneal retractor.

In addition, in some embodiments, the Deaver Retractor 3810 on theposterior side of the disc space can also be swapped out to incorporatea different blade of the medical device 10 (e.g., peritoneal retractor).Advantageously, both blades of the medical device 10 can beadvantageously mounted to arms, which can be mounted to a table top,thereby freeing the surgeons hands and preventing overwork andexhaustion. The blades can be held by arms (e.g., such as from GlobusMedical's MARS™ 3V system), which can be attached to a table mount.Advantageously, the blades are held by the arms and are thus hands-free.

After retraction, access can be provided to the transpoas, as discussedwith respect to FIGS. 24 and 25 above. The rest of the surgicalprocedure described in FIGS. 26-38, including the use sequentialdilation, can be applied hereafter. One skilled in the art willappreciate that in some embodiments, the use of rigid retractors (e.g.,Deaver Retractors 3810, 3812) can also be used in addition (rather thanas a substitution) to the use of a wound retractor discussed above.Furthermore, one skilled in the art can appreciate how any of theretractors discussed above can be used with various implants. Forexample, after performing a sequential dilation and inserting a thirdretractor (e.g., a MARS 3V retractor from Globus Medical), access isprovided to the disc space. Various fusion implants, such as theexpandable implant found in U.S. Ser. No. 14/199,594, filed Mar. 6,2014, or the plate-spacer system found in U.S. Ser. No. 14/139,127,filed Nov. 2, 2012 (both of which are incorporated by reference in theirentireties) can then be inserted into the disc space. These implantsadvantageously can used in a fusion procedure and can be used with otherimplants, including spinal stabilization systems utilizing rod members.

While certain features of the described implementations have beenillustrated as described herein, many modifications, substitutions,changes and equivalents will now occur to those skilled in the art. Itis, therefore, to be understood that the appended claims are intended tocover all such modifications and changes as fall within the scope of theembodiments. It should be understood that they have been presented byway of example only, not limitation, and various changes in form anddetails may be made. Any portion of the apparatus and/or methodsdescribed herein may be combined in any combination, except mutuallyexclusive combinations. The embodiments described herein can includevarious combinations and/or sub-combinations of the functions,components and/or features of the different embodiments described.

What is claimed is:
 1. A surgical method comprising: creating anincision in a patient; inserting a first rigid retractor by hand in thepatient in an anterior position relative to a disc space; inserting asecond rigid retractor by hand in the patient in a posterior positionrelative to the disc space, wherein the first rigid retractor and thesecond rigid retractor are each inserted independent of one another forindependent maneuverability; using the first rigid retractor and thesecond rigid retractor to retract tissue in the patient; removing atleast one of the first rigid retractor and the second rigid retractorfrom the patient and inserting an assembly blade that is mounted to atable and hands-free wherein the articulating arm is configured totranslate and angulate, wherein the entire first retractor is spacedapart from the entire second retractor, wherein the assembly blade isattached to a handle portion at a proximal end of the blade via a hingemechanism.
 2. The surgical method of claim 1, wherein the first rigidretractor and the second rigid retractor each comprise a DeaverRetractor.
 3. The surgical method of claim 1, wherein the first rigidretractor is positioned closer to a peritoneum of the patient than thesecond rigid retractor.
 4. The surgical method of claim 3, wherein thefirst rigid retractor is used to dissect fat off of the peritoneum. 5.The surgical method of claim 4, wherein the first rigid retractor isused to retract the peritoneum anteriorly above psoas tissue.
 6. Thesurgical method of claim 1, wherein the first rigid retractor and thesecond rigid retractor are used to retract a peritoneum of the patientand expose a psoas of the patient.
 7. The surgical method of claim 6,wherein the assembly blade helps to provide a direct look at the psoaswithout the use of a neuomonitoring device.
 8. The surgical method ofclaim 6, wherein the assembly blade incorporates a light source toprovide a direct look at the psoas.
 9. The surgical method of claim 1,further comprising removing both the first rigid retractor and thesecond rigid retractor, and inserting the assembly blade and a secondassembly blade attached to a singular mount into the patient.
 10. Thesurgical method of claim 9, further comprising inserting a thirdretractor into the incision and inserting a fusion implant therethroughto be implanted in a disc space.